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In the News

for the Week of 3-30-11

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Highlights

AHA releases scientific statement on managing PE, DVT

The American Heart Association last week issued a scientific statement on the management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension. More...

Readmissions difficult to predict, study finds

Neither providers nor an algorithm accurately predicted which patients had the highest risk of readmission, a new study found. More...

Cardiology

ACC, AHA release focused update on management of unstable angina, non-ST-elevation MI

The American College of Cardiology/American Heart Association released a focused update this week to their guidelines on management of unstable angina and non-ST-elevation myocardial infarction. More...

Critical care

Dalteparin not superior to unfractionated heparin for preventing proximal DVT in the critically ill

The low-molecular-weight heparin dalteparin was not superior to unfractionated heparin for preventing deep venous thrombosis in critically ill patients, a new study found. More...

COPD

Tiotropium reduces risk of moderate, severe COPD exacerbations

The anticholinergic drug tiotropium is superior to the β2-agonist salmeterol as first-line maintenance therapy to prevent exacerbations of chronic obstructive pulmonary disease in patients with moderate to very severe stages, a study found. More...

Internal Medicine 2011

ACP Job Placement Center calls for job seekers' profiles

Physicians looking for a new job may submit a profile to the ACP Job Placement Center, a service available at Internal Medicine 2011, to be held April 7-9 in San Diego. More...

Cartoon Caption Contest

And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...

Physician editor: A. Scott Keller, FACP

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Highlights

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AHA releases scientific statement on managing PE, DVT

The American Heart Association last week issued a scientific statement on the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (DVT), and chronic thromboembolic pulmonary hypertension (CTEPH).

The ACC proposed definitions for massive and submassive PE. Massive PE is an acute PE with sustained hypotension (systolic blood pressure of 90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular dysfunction), pulselessness, or persistent profound bradycardia (heart rate 40 beats per minute with signs or symptoms of shock). Submassive PE is an acute PE without systemic hypotension (systolic blood pressure 90 mm Hg) but with either right ventricular dysfunction or myocardial necrosis.

Recommendations include:

• Patients with objectively confirmed acute pulmonary embolism and no contraindication to therapeutic anticoagulation should be given subcutaneous low-molecular-weight heparin, intravenous or subcutaneous unfractionated heparin (UFH) with monitoring, unmonitored weight-based subcutaneous UFH, or subcutaneous fondaparinux. These should be given during the diagnostic workup for those with intermediate or high clinical probability of PE and no contraindications.
• Fibrinolysis is reasonable for patients with massive acute PE and acceptable risk of bleeding complications, and also may be considered for those with submassive acute PE with clinical evidence of adverse prognosis (new hemodynamic instability, worsening respiratory failure, severe right ventricular dysfunction, or major myocardial necrosis) and low bleeding risk. It is not recommended for patients with low-risk PE or undifferentiated cardiac arrest.
• For patients with massive PE and contraindications to fibrinolysis, or who remain unstable after fibrinolysis, either catheter embolectomy and fragmentation or surgical embolectomy is reasonable, depending on local expertise. These treatments also may be considered for those with submassive acute PE with clinical evidence of adverse prognosis.
• Adults with confirmed acute PE or proximal DVT with contraindications to anticoagulation or with active bleeding complication should receive an inferior vena cava (IVC) filter. Once contraindications or complications have resolved, anticoagulation should be resumed.
• IVC filters are reasonable for patients with recurrent acute PE despite therapeutic anticoagulation, and may be considered for those with acute PE and very poor cardiopulmonary reserve, including those with massive PE. A filter should not be used routinely as an adjuvant to anticoagulation and systemic fibrinolysis for acute PE.
• Adult patients with iliofemoral deep vein thrombosis (IFDVT) who take oral warfarin as first-time, long-term anticoagulation should have warfarin overlapped with initial anticoagulation for a minimum of five days and until the INR is 2.0 or higher for at least 24 hours, then targeted to an INR of 2.0 to 3.0.
• Patients with IFDVT should wear 30- to 40-mm Hg knee-high graduated elastic compression stockings on a daily basis for two years to help prevent post-thrombotic syndrome.
• Patients with objectively proven CTEPH should be promptly evaluated for pulmonary endarterectomy, even if symptoms are mild.
• Patients with objectively proven CTEPH should receive indefinite therapeutic anticoagulation in the absence of contraindications.

The statement was published online March 21 by Circulation.

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Readmissions difficult to predict, study finds

Neither providers nor an algorithm accurately predicted which patients had the highest risk of readmission, a new study found.

Researchers used the electronic medical record at the University of California, San Francisco Medical Center to screen general medicine admissions for eligible patients, and to identify readmissions. Phone calls were also used for the latter. Study patients comprised 164 adults at least 65 years old who were discharged from the general medicine service. Provider subjects included 24 attending physicians, 42 housestaff physicians, six case managers and more than 30 nurses. At discharge, providers estimated a patient's chance of unscheduled readmission within 30 days and predicted the reason for possible readmission. Researchers also calculated the Probability of Repeat Admission (Pra) for each patient. The Pra is an algorithm for predicting the probability of at least two hospital readmissions during a four-year period, based on eight risk factors including age, self-rated health, and prior hospital admission in the past year. Results were published online March 12 in the Journal of General Internal Medicine.

Five enrolled patients died within 30 days of discharge. Of the remaining patients, 32.7% (n=52) were readmitted, and 4.4% (n=7) presented to the emergency department but weren't readmitted. Mean readmission predictions by physicians were closest to the actual rates (attendings 33.0%, residents 30.0%, interns 31.5%). Readmissions were overestimated by the Pra (41.5%), nurses (43.5%) and case managers (39.0%). The P value was less than 0.05 for the comparison of nurses, case managers and the algorithm with the actual readmission rate. By receiver-operating characteristic curves, the ability to discriminate between readmissions and nonreadmissions was poor for all provider groups and for the Pra (AUC of 0.50 for nurses, 0.56 for Pra and 0.59 for interns). Discriminatory ability was best for the intern physician group, followed by attending and resident physicians and the Pra, but these findings weren't statistically different from 0.50 (i.e., chance). No provider group accurately predicted the reasons for readmission (i.e., predicted the correct or a related diagnosis more than 51% of the time); nurses and interns had the highest accuracy. All groups underestimated the degree to which patients would be readmitted for adverse effects of therapy.

The readmission rate in this study is significantly higher than the 19.6% readmission rate seen in a 2009 New England Journal of Medicine study of nearly 12 million Medicare patients, the authors noted, possibly because the current study involved tertiary care patients in an urban setting. The inability of providers to predict readmissions defied the researchers' original hypothesis that experience would make the providers ideal for the task, they wrote. Each provider has a unique viewpoint on the patient; it's possible the predictions may have been more accurate had all providers collaborated, the authors theorized. Possible reasons for poor predictions include the heterogeneity of general medicine patients; overlooked elements that factor into readmission like complications from treatment, including adverse drug events; and influences like processes of care during hospitalization and post-discharge care. Given this study's findings that readmission is common and unpredictable, the proposed changes for public reporting and reimbursement for readmissions leave hospitals "to struggle without guidance to aim their efforts" to reduce readmissions, the authors wrote.

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Cardiology

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ACC, AHA release focused update on management of unstable angina, non-ST-elevation MI

The American College of Cardiology/American Heart Association released a focused update this week to their guidelines on management of unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI). The guidelines were originally issued in 2007.

For this update, the guideline writing committee examined areas of new research: the timing of acute interventional therapy in patients with NSTEMI; the timing, duration and application of dual-antiplatelet therapy and triple-antiplatelet therapy in high-risk patients and dual-antiplatelet therapy in low- and moderate-risk patients; the role of invasive therapies in patients with advanced renal dysfunction; and the effect of participation in a quality-of-care data registry for UA/NSTEMI on quality improvement for acute coronary syndromes.

New recommendations in the focused update include the following:

• Patients with UA/NSTEMI for whom percutaneous coronary intervention (PCI) is planned should receive a loading dose of a thienopyridine.
• Clopidogrel, 75 mg/d, or prasugrel, 10 mg/d, should be given for at least a year after PCI, unless the risk of bleeding outweighs the potential benefits.
• In patients with UA/NSTEMI who are planning to have PCI and have a history of stroke or transient ischemic attack, prasugrel may be harmful if used as dual-antiplatelet therapy.
• Platelet function testing may be considered in patients with UA/NSTEMI receiving thienopyridine therapy to evaluate platelet inhibitory response if the results of such testing might change management.
• An early invasive treatment strategy (within 12 to 24 hours of hospital admission) is considered reasonable in stabilized high-risk patients with UA/NSTEMI. A delayed invasive approach is considered reasonable for patients who are not at high risk.
• Continuing clopidogrel or prasugrel beyond 15 months after placement of a drug-eluting stent may be considered.
• Patients with chronic kidney disease who are having cardiac catheterization with contrast media should receive adequate hydration beforehand.
• Clinicians and hospitals caring for patients with UA/NSTEMI may reasonably participate in a standardized quality-of-care data registry to track and measure outcomes, complications and adherence to evidence-based care.

The focused update will be published in the Journal of the American College of Cardiology and Circulation and is available online at the ACC and AHA websites.

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Critical care

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Dalteparin not superior to unfractionated heparin for preventing proximal DVT in the critically ill

The low-molecular-weight heparin dalteparin was not superior to unfractionated heparin for preventing proximal leg deep venous thrombosis (DVT) in critically ill patients, but the dalteparin group did have a secondary outcome of fewer pulmonary emboli, a new study found.

Researchers performed a randomized, multicenter trial to determine whether low-molecular-weight heparin would outperform unfractionated heparin for thromboprophylaxis against proximal DVT. A total of 3,746 patients in intensive care units were randomly assigned to receive subcutaneous dalteparin, 5,000 IU once daily plus placebo once daily, or unfractionated heparin, 5,000 IU twice daily. The primary outcome was proximal leg DVT on compression ultrasonography performed within two days after admission, twice per week, and when clinically indicated. The secondary outcomes were any DVT, pulmonary embolism, venous thromboembolism (VTE), death, a composite of VTE or death, major bleeding, and heparin-induced thrombocytopenia. The study results were published online March 22 by the New England Journal of Medicine.

Eligible patients were at least 18 years old, weighed at least 45 kg (99 lb) and had an expected intensive care unit stay of at least three days. Of the 3,746 patients, 1,873 were randomly assigned to receive dalteparin and 1,873 were randomly assigned to receive unfractionated heparin. In intention-to-treat analysis, the rate of proximal leg DVT did not differ between the dalteparin group and the unfractionated heparin group (5.1% vs. 5.8%). The hazard ratio for the dalteparin group was 0.92 (95% CI, 0.68 to 1.23; P=0.57). Patients in the dalteparin group had a significantly lower rate of pulmonary embolism than those in the unfractionated heparin group (1.3% vs. 2.3%; hazard ratio, 0.51; 95% CI, 0.30 to 0.88; P=0.01), as well as a lower rate of heparin-induced thrombocytopenia (0.3% vs. 0.6%; hazard ratio, 0.27; 95% CI, 0.08 to 0.98; P=0.046). Rates of major bleeding and in-hospital death did not significantly differ.

The authors noted that their results were limited by their use of screening compression ultrasonography to detect DVT, and noted that they might have had different findings if more patients had been enrolled or different drug regimens had been used. They concluded that in this study of critically ill medical and surgical patients, the low-molecular-weight heparin dalteparin was not superior to unfractionated heparin for preventing proximal DVT. Although patients receiving dalteparin were significantly less likely to develop pulmonary embolism, this finding was not accompanied by a corresponding significant decrease in the rate of proximal DVT. Possible explanations, according to the authors, include embolism from other sites, an effect of dalteparin on the propensity of leg thrombi to embolize, new-onset thrombus formation in pulmonary arteries during critical illness, and insensitivity or nonspecificity of proximal ultrasonography in asymptomatic patients.

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COPD

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Tiotropium reduces risk of moderate, severe COPD exacerbations

The anticholinergic drug tiotropium (brand name: Spiriva) is superior to the β2-agonist salmeterol (brand name: Serevent) as first-line maintenance therapy to prevent exacerbations of chronic obstructive pulmonary disease (COPD) in patients with moderate to very severe stages, a study found.

The Prevention of Exacerbations with Tiotropium in COPD (POET-COPD) trial was a one-year, randomized, double-blind, double-dummy, parallel-group trial at 725 centers in 25 countries. Researchers compared tiotropium to salmeterol to assess the incidence of moderate or severe exacerbations in patients with moderate to very severe COPD and a history of exacerbations in the previous year. A total of 7,376 patients were randomly assigned to and treated with 18 μg of tiotropium once daily or 50 μg of salmeterol twice daily between January 2008 and April 2009. The primary end point was the time to the first exacerbation, defined as an increase in or new onset of more than one symptom (such as cough, sputum, wheezing, dyspnea or chest tightness) with at least one symptom lasting three days or more and leading to treatment with systemic glucocorticoids, antibiotics, or both (moderate exacerbation) or to hospitalization (severe exacerbation). Results appeared in the March 24 New England Journal of Medicine.

Tiotropium increased the time to the first exacerbation (187 days vs. 145 days), with a 17% reduction in risk (hazard ratio [HR], 0.83; 95% CI, 0.77 to 0.90; P<0.001). Because 36.5% (n=2,691) of patients had an exacerbation, time to the first exacerbation in the first quartile of patients was calculated instead of the median.

Tiotropium significantly reduced the annual rate of exacerbations by 11% (rate ratio, 0.89; 95% CI 0.83-0.96; P=0.002). It also reduced the risk of moderate exacerbations by 14% (HR, 0.86; 95% CI, 0.79 to 0.93; P<0.001) and of severe exacerbations by 28% (HR, 0.72; 95% CI, 0.61 to 0.85; P<0.001). In addition, tiotropium reduced the risk of exacerbations leading to treatment with systemic glucocorticoids by 23% (HR, 0.77; 95% CI, 0.69 to 0.85; P<0.001), treatment with antibiotics by 15% (HR, 0.85; 95% CI, 0.78 to 0.92; P<0.001), and treatment with both by 24% (HR, 0.76; 95% CI, 0.68 to 0.86; P<0.001). Benefits appeared as early as one month and lasted the duration of the one-year study. Serious adverse events, adverse events that stopped therapy, and deaths were similar between the two groups.

An editorialist wrote, "The main implications of this trial are for the initial care of symptomatic patients with moderate disease and a history of recent exacerbations. ... There is no evidence for the superiority of tiotropium in patients with mild COPD (those in whom the FEV1 is >70% of the predicted value) or symptomatic patients with moderate COPD but without a history of exacerbations."

For more on managing COPD in hospitalized patients, read ACP Hospitalist's March cover story.

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Internal Medicine 2011

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ACP Job Placement Center calls for job seekers' profiles

Physicians looking for a new job may submit a profile to the ACP Job Placement Center, a service available at Internal Medicine 2011, to be held April 7-9 in San Diego.

The center, located in the San Diego Convention Center's Exhibit Hall, Booth #1601, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Profiles will be included in one of two booklets distributed only to Job Placement Center sponsors and exhibitors who have submitted a job posting that meets your criteria. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the center. Profiles can be submitted online.

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Cartoon Caption Contest

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And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

We find that compliance improves when you only have to take one pill a day."

This issue's winning cartoon caption was submitted by David A. Tipton, FACP. Readers cast 136 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 57.4% of the votes.

The runners-up were:

"I thought baby aspirin meant the lower dose, not the size of a human baby."

"Americans just didn't want to deal with milligrams anymore."

Editorial note: There will be no ACP HospitalistWeekly on April 6, due to preparations for the Internal Medicine 2011 meeting in San Diego on April 7-9. Our April 13 issue will feature highlights from the meeting.

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